Family Planning

FAMILY PLANNING.

Family planning refers to the use of modern contraception and other methods of birth control to regulate the number, timing, and spacing of human births. It allows parents, particularly mothers, to plan their lives without being overly subject to sexual and social imperatives. However, family planning is not seen by all as a humane or necessary intervention. It is an arena of contestation within broader social and political conflicts involving religious and cultural injunctions, patriarchal subordination of women, social-class formation, and global political and economic relations.

Attempts to control human reproduction is not entirely a modern phenomenon. Throughout history, human beings have engaged in both pro-and antinatalist practices directed at enhancing social welfare. In many foraging and agricultural societies a variety of methods such as prolonged breast-feeding were used to space births and maintain an equilibrium between resources and population size. But in hierarchical societies, population regulation practices did not bring equivalent or beneficial results to everyone. Anthropologists Marvin Harris and Eric Ross have shown that "As power differentials increase, the upper and lower strata may, in fact, develop different or even antagonistic systems of population regulation" (p. 19).

Being uniquely endowed with the capacity for reproduction, women of course have borne the costs of pregnancy, birth, and lactation, as well as abortion and other stressful methods of reproductive regulation. Social-class dominance over reproduction often takes place through the control of lower-class women by upper-class men. The particular forms these controls take vary across historical periods and cultures. In feudal agricultural and "plantation economies" experiencing labor shortages and short life expectancies, for example, there has been great pressure on women to bear as many children as possible.

In the modern era of industrial capitalist development, conservative fundamentalist groups have tended to oppose abortion and reproductive choice for women on grounds of religion and tradition. They believe that abortion and contraception are inimical to the biological role of women as mothers and to the maintenance of male-dominant familial and community arrangements. In both the industrialized north and the poor countries of the south, religious fundamentalists oppose abortion and the expansion of reproductive choices for women, and sometimes they do so violently, as in the attacks in the United States against clinics and doctors providing legal abortions. The rapid spread of evangelical Christianity and militant Islam around the world further aggravate the situation.

Partly as a result of religious fundamentalist opposition, in the early twenty-first century abortion remains illegal in many countries. It is estimated that worldwide approximately 200,000 women die annually due to complications from illegal abortions. The actual figures may be higher, since only about half the countries in the world report maternal mortality statistics. Indeed, the unchallenged position of the Vatican against artificial conception and the U.S. government policy against funding for international abortions has led some to believe that illegal abortions and maternal mortality could further increase. Not only does the Bush administration refuse money for abortions, but it also prohibits medical professionals in international organizations such as International Planned Parenthood from talking about abortion if they receive U.S. government support. In the context of both the conservative religious backlash and the problems attributed to global population expansion, family planning seems an enlightened and progressive endeavor. Yet, the movement to provide modern contraception has been fraught with gender, race, and class inequalities and health and ethical problems from the outset. Efforts to reform and democratize international family planning must necessarily grapple with these concerns.

Origin and Evolution of Family Planning

The idea of modern population control is attributed to Thomas Malthus (1766–1834), who in 1798 articulated his doctrine attributing virtually all major social and environmental problems to population expansion associated with the industrial revolution. However, as a clergyman turned economist, Malthus was opposed to artificial methods of fertility control. He advocated abstinence and letting nature take its toll and allowing the poor to die.

In contrast, birth control emerged as a radical social movement led by socialists and feminists in the early twentieth century in the United States. The anarchist Emma Goldman (1869–1940) promoted birth control not only as a woman's right and worker's right, but also as a means to sexual freedom outside of conventional marriage. But soon birth control became increasingly medicalized and associated with science and corporate control as well as with the control of reproduction within marriage and conventional family life. As the radicals
lost their leadership of the birth control movement to professional experts, mostly male doctors, by the 1920s birth control, which refers to voluntary and individual choice in control of reproduction, became aligned with population control, that is, a political movement by dominant groups to control the reproduction of socially subordinate groups.

During the influx of new immigrants in the 1920s and 1930s and during the depression, when the ranks of the unemployed were swelling, eugenicist (hereditary improvement) ideology and programs for immigration control and social engineering gained much ground in the United States. Even the birth-control pioneer Margaret Sanger (1879–1966) and suffragists such as Julia Ward Howe (1819–1910) and Ida Husted Harper (1851–1931) surrendered to ruling-class interests and eugenics, calling for birth control among the poor, blacks, and immigrants as a means of counteracting the declining birth rates of native-born whites. Influenced by eugenicist thinking, twenty-six states in the United States passed compulsory sterilization laws, and thousands of persons—mostly poor and black—deemed "unfit" were prevented from reproducing. By the 1940s, eugenicist and birth-control interests in the United States were so thoroughly intertwined that they became virtually indistinguishable. In the post–World War II era, compulsory sterilization became widespread in the so-called Third World where the birth rates have been higher than in the industrialized countries (in 1995, fertility per woman was 1.9 in the more developed regions and 3.6 in the less developed regions).

In the late twentieth century, the fear of demographic imbalance again seemed to be producing differential family-planning policies for the global north and the south. This was evident in corporate-scientific development of stronger contraceptives largely for poor women of color in the south and new reproductive technologies for fertility enhancement largely for white upper-class women in the north. Some insurance companies in the United States continue to refuse to cover conception in the early twenty-first century. Countries concerned with population "implosion" in the north such as Sweden, France, and Japan are pursuing pronatalist policies encouraging women to have more children while at the same time pursuing antinatalist policies encouraging women in the south to have fewer children.

Family Planning in the Global South

Given the massive increase in population in the south hemisphere countries since World War II, much of global family-planning efforts have been directed toward those poor countries of the so-called Third World. The followers of Malthus, the neo-Malthusians, have extended his thinking, blaming global poverty, political insecurity, and environmental degradation on the "population explosion" and calling for population control as the primary solution to these problems. Their efforts have helped turn family planning into a vast establishment of governmental and nongovernmental organizations with financial, technological, and ideological power emanating from the capitals in the north toward the remote corners of the south. Within countries in the south, the hierarchical family-planning model spreads from professional elites in the cities to the poorest men and women in the villages. In India alone, there are an estimated 250,000 family-planning workers. Every year vast amounts of money are spent to promote "contraceptive acceptance" among the poor populations in the world. Contraceptive use in the "developing world" has increased from less than 10 percent of couples of reproductive age in the 1960s to more than 50 percent (42 percent excluding China) in the 1990s. The rapidly falling birth rates in the Third World are generally attributed to the "family-planning revolution" represented by expanding use of modern contraceptives.

The International Conference on Population and Development (ICPD), held in Cairo in 1994, is generally considered to have ushered in a new approach to population and development, upholding reproductive health and rights of women over meeting numerical goals for reducing fertility and population growth. Departing from earlier positions and upholding voluntary choice in family size, the ICPD Programme of Action states that demographic goals in the form of targets and quotas for the recruitment of clients should not be imposed on family-planning providers and expresses disapproval
of the use of incentives and disincentives. It acknowledges the setting of demographic goals as a legitimate subject of state development strategies to be "defined in terms of unmet needs for [family-planning] information and services" (United Nations, 1994). But, as human rights activists concerned with continued abuses in family-planning programs point out, there is still a long way to go in establishing policies and ethical standards to ensure that the new health and women's rights objectives are achieved.

Notwithstanding massive spending and extensive family-planning promotion over three decades, many poor people in the Third World remain reluctant to use modern contraception in the early twenty-first century. Attitudes and the need for children among the poor are often quite different from that of family-planning enthusiasts, who are mostly middle-class professionals. Even when poor people use modern contraceptives, their continuation rates are often low due to lack of access to health care, side-effects of contraceptives, and other reasons. Given these realities and the urgency to reduce fertility, international family planning continues to rely on the use of economic incentives and disincentives as well as highly effective, provider-controlled, female methods.

Although male sterilization (vasectomy) is a much simpler operation than female sterilization (tubectomy), female sterilization is the most favored method of family planners and the most widely used method of fertility control in the world. Tubectomy is more common than vasectomy because the men in many areas refuse to have vasectomies, leaving the women little choice if they don't want more children. Female sterilization constituted about 33 percent and male sterilization 12 percent of all contraceptive use in the developing countries at the end of the 1980s. In terms of the numbers, sterilization is an increasing success, and for many women and men in the north and the south, sterilization represents a choice to be free of biological reproduction. But closer examination of conditions under which most women consent to be sterilized shows that sterilization abuse continues to be a pervasive problem for poor women.

Poverty and adverse social conditions—including lack of information and access to other methods of birth control, threats of discontinued social benefits, and economic constraints—set the conditions for abuses in family-planning programs. Targets and economic incentives/disincentives have defined the operation of many Third World family-planning programs from their inception. They have also been associated with programs directed at poor communities of color in the United States. In the early 2000s a nonprofit organization known as C.R.A.C.K. (Children Requiring A Caring Kommunity) promised a cash incentive of $200 to drug-addicted women upon verification that they had been sterilized or were using a long-term birth control method such as Norplant, Depo-Provera, or an IUD (American Public Health Association).

While targets and incentives in other realms of social policy are not necessarily wrong, the pressure to meet targets and the offer of economic incentives in family-planning programs have resulted in a highly techno-bureaucratic and monetarist approach obsessed with numbers of acceptors and financial rewards. Within such a quantitative approach, the complex psychological, sociocultural dimensions of sexuality and reproduction are easily overlooked. Not only do poor people lack much relevant information, but also, in many cases, the desperation of poverty drives them to accept contraception or sterilization in return for payments in cash or kind. In such situations, choice simply does not exist. Direct force has reportedly been used in population-control efforts in some countries, including China, India, Bangladesh, and Indonesia. But coercion does not pertain simply to the outright use of force. More subtle forms of coercion arise when individual reproductive decisions are tied to sources of survival, like the availability of food, shelter, employment, education, health care, and so on.

The "Second Contraceptive Revolution"

Claiming that the earlier contraceptive revolution was a major success, the international family-planning establishment declared the launching of a "second contraceptive revolution" and a "contraceptive 21 agenda" for the twenty-first century. This, like the earlier phase, upheld the biomedical model of mass female fertility management. In 2004 about ninety-four new contraceptive products were being pursued, of which many were variants of existing methods. Among these were four IUDs, seven hormonal implants, five hormonal injectables, five hormonal pills, six vaccines, and six methods for female sterilization.

The second contraceptive revolution also envisaged a greater role for private industry. Given the "latent demand" for new contraceptives, liberalization of trade, privatization of state-run enterprises, and other factors, contraceptive marketing in the Third World promised to be even more profitable for pharmaceutical companies than they had been in the past. The privatization of health sectors, increasing corporate mergers (such as the merger of Pharmacia Sweden and Upjohn of the United States), and the extension of intensive contraceptive promotional and marketing strategies further augmented the power and profits of transnational pharmaceutical companies in the south.

The United States Food and Drug Administration (USFDA) in the early 2000s was completely exempting more and more drugs and medical devices from review before marketing, a move that could have detrimental repercussions across the world. The ICPD and its "new" reproductive-rights agenda, however, did not address the need for strict guidelines to monitor contraceptive trials and the marketing practices of corporations. Calls for population stabilization in the context of GATT (General Agreement on Trade and Tariffs) and other "free trade" agreements, could result in further easing of protocols for contraceptive trials. Feminist activists fear increased corporate dumping of dangerous and experimental contraceptives on the bodies of poor women. Their concerns are based on the history of experimentation of contraceptives such as Depo-Provera and Norplant on poor women in the north and the south without informed consent, the use in the Third World of the Dalkon Shield IUD and other contraceptive devices banned in the United States, and other unethical and dangerous practices. The FDA has, however, been stalling on making emergency contraception available over the counter,
maintaining that it needs further testing. Planned Parenthood, NOW, and NARAL, among other feminist organizations, have long urged the approval of the drug.

Health and Human Rights of Women

Modern family-planning programs have provided many poor women with contraceptives and the ability to limit family size; but they have rarely given women genuine choice, control over their bodies, or a sense of self empowerment. The focus of family planning has been on population stabilization and the meeting of targets rather than on the means or the processes to achieve its ends. Although many family planners in the early 2000s call for women's reproductive rights, population-control programs seem to be moving in authoritarian directions.

Article 16 of the Teheran Proclamation issued by the United Nations Conference on Human Rights in 1968 states that "Parents have a basic human right to determine freely and responsibly the number and spacing of their children" (United Nations, 1974). This Article represented a major victory for the population-control movement. Perhaps the term "responsibly" was the real victory because it can be interpreted in a more-or-less coercive way. Indeed, the overwhelming importance given by international donors and local governments to fertility control has led to a relative neglect of other aspects of family planning and reproductive and human rights such as the right of the poor to health and well-being, including the right to bear and sustain children. Indeed, the neglect of the survival issues by the family planners has allowed right-wing fundamentalists to appear as the only ones concerned with family and community.

The emphasis on family planning has undermined public health care and Maternal and Child Health (MCH) in many countries. In 2004, many of the new hormonal and immunological contraceptives did not protect against HIV/AIDS. In many poor communities in Africa ridden with AIDS, modern contraception was widely available while pharmaceutical drugs for AIDS were not. Target pressure and incentives continued to drive interests of health-care personnel toward population control over provision of health care. Population agencies spoke in public of integrating family planning within a broader health-care framework. But in private some have argued that family-planning programs should not be "held hostage" to strict health requirements and that maximum access to contraceptives should override safety and ethical concerns. Even when the population-control organizations have taken efforts to address public-health issues and women's social and economic rights, the population-control objective has continued to be dominant. The Safe Motherhood Initiative is an example.

The Safe Motherhood Initiative was launched by the World Bank, United Nations Development Program, United Nations Children's Fund (UNICEF), United Nations Fund for Population Activities (UNFPA) and the World Health Organization (WHO) to reduce maternal mortality. In many cases, this initiative has aimed simply to reduce childbearing; the assumption being that fewer births will cause fewer maternal deaths. A 1992 World Bank evaluation of its population-sector work admitted that its foray into broader health initiatives had been motivated by the "political sensitivity" of population control and the need to dissipate Third World perception that "population control is really the Bank's strategic objective." The report further notes that many countries that would not accept donor support for population control would nevertheless "accept support for family health and welfare programs with family planning components" and that the likelihood of family planning getting "lost in an MCH program" was less because MCH was better accepted as a "legitimate intervention for both health and demographic reasons" (World Bank, 1992).

As Indian health researcher Malini Karkal has pointed out, the tendency to attribute maternal mortality simply to pregnancy and childbirth by the Safe Motherhood Initiative and other such programs has led to a relative neglect of causes of reproductive mortality that supercede maternal mortality. Deaths due to unsafe sterilization, hazardous contraceptives, deaths associated with sexually transmitted diseases, cancer of the reproductive organs, and unsafe treatment of infertility also account for a large proportion of reproductive mortality. Where births have been "averted" due to family-planning programs, the reproductive choices or conditions of women or of the general population, for that matter, have not increased as a result. In India, although birth rates have declined, infant mortality at about 72 per 1,000 births and maternal mortality at about 460 per 100,000 live births in 1995 continued to be relatively high. As women's-rights advocates argue, improvement of the status of women is not the consequence of family-planning programs as believed by the population planners. Rather it is a more complex outcome resulting from rise of age in marriage, education, employment, better living conditions, and general awareness, as well as family planning. Indeed, everywhere, voluntary acceptance of contraception seems to be correlated with women's access to education.

Phenomenon of "Missing Women"

In the 1980s and 1990s in several Asian countries, the proportion of girls born and living appeared to be steadily decreasing. In India, the ratio of women to men was 929 females to 1,000 males, whereas in 1901 it was 972. In China after the one-child family policy was implemented in 1979, the sex ratio became more skewed. There were 94.1 women per 100 males in the 1982 census; in the 1990 census, there were only 93.8 females per 100 males. Demographic data shows that in the early 2000s in China, India, Pakistan, Bangladesh, Nepal, West Asia, and Egypt, 100 million or more women were unaccounted for by official statistics. Further skewing of sex ratios particularly in the world's two most populous countries, India and China, are likely to create serious demographic and gender issues in the future.

One factor contributing to the problem of "missing women" is sex-selective abortions. New technologies such as amniocentesis, ultrasound, and chorionic biopsy, developed for purposes of prenatal testing for birth defects, are increasingly used for the purpose of sex determination. Sex-selection procedures are increasingly advertised in the United States as scientific advances intended to improve choice in family planning and they are likely to become routine procedures. In the patriarchal societies of China and India, where the preference for male children and the pressures to reduce family size are
both very strong, abortions of female fetuses seem to be widespread. Although the use of technologies for sex selection is illegal in China, they are readily available even in rural areas. With a small bribe, parents can easily find out the sex of the embryo and abort it if it is female, thus ensuring that the only child allowed by the State's one-child-family law be a male.

In India too, sex-selective abortion is a thriving business. According to some estimates, between 1978 and 1983 alone, 78,000 female fetuses were aborted after sex-determination tests. Researchers have found that some poor districts in Uttar Pradesh, Maharashtra, and Gujarat, which do not have basic services such as potable water and electricity, have clinics doing a flourishing business in prenatal diagnostic techniques for sex selection. Even poor farmers and landless laborers were willing to pay 25 percent compound interest on loans borrowed to pay for those tests. Given extreme social pressures to produce sons, many women, not only poor uneducated women, but also educated urban women are resorting to abortion of female fetuses. Some middle-class Indian women justify these actions on grounds of choice, and some medical doctors and intellectuals have also argued that it would prevent the suffering of women and that in the long run the shortage of women would lead to their improved status in society. Nurses seeking to meet their family-planning targets actively encourage "scanning" for sex determination and abortion of female fetuses. Some doctors also promote sex-selective abortion as an effective method of population control that would allow the Indian government to achieve its population-control targets.

Female infanticide and underreporting of girls are other factors contributing to the "missing women" phenomenon. The Chinese government has either denied or condemned the practice of female infanticide, but reliable data are not available. Female infanticide does have a long tradition in patriarchal societies such as China and India. But as the demographer Terrence Hull has noted, the "behavioral and emotional setting of infanticide in contemporary China" tends to be substantially different from the traditional pattern (Hull p. 73). The resurgence of infanticide since the early 1980s, is at least partly related to the pressures of the Chinese family-planning program, and the infants killed at birth have been overwhelmingly female. Most of the abandoned infants who end up in state-run orphanages are girls. Many of these girls, as well as boys, are subjected to starvation, torture, and sexual assault. Women's rights activist Viji Srinivasan, who has studied female infanticide among poor communities in Tamil Nadu, India, has also identified the "internalization of the small family norm" due to family-planning promotion as a source of female infanticide (pp. 53–56). Her study raises questions about the ethics of aggressive population control in highly patriarchal societies and underscores the need for economic empowerment and elevation of women's status.

Family Planning and Authoritarianism

Family-planning advocates and organizations claim that the modern "contraceptive revolution" has been achieved without coercion, through "purely voluntary means" with only "minor disadvantages" to people in the Third World (UNFPA). But a closer examination of the methods of contraception and strategies of family planning reveals widespread human-rights violations and safety and ethical problems. In this regard, it is well to remember the arguments commonly put forward by influential neo-Malthusian demographers, according to whom political will and strong measures need to be used in the fight against population growth, and democratic norms may have to be sacrificed for the sake of the greater good.

Some analysts argue that neo-Malthusian family planning is a quantitative, technical, and bureaucratic approach driven by urgency and aggression to reduce the numbers of the human population in a race against the mechanical clock. Controlled by money and political influence, it has erected a vast global family-planning enterprise far removed from the broader economic needs and cultural interests of the masses whose numbers it seeks to control. Such a hierarchical and at times violent approach can reinforce existing psychosocial structures of domination and subordination; men over women (patriarchy); capital over labor (capitalism); north over south (imperialism); white over people of color (white supremacy/racism); and so on.

Dualistic thinking, the separation of self and other and of subject and object, lies at the root of neo-Malthusianism. As such, it is unable to comprehend the inherent connectedness between the self and the other. Fear of the unknown and desire for permanence and control, in this case, the control of the global masses and their reproduction, underlies this dichotomous thinking. As a fragmented, top-down, and homogeneous approach, Malthusianism leaves no room for more balanced, qualitatively oriented participatory and diverse approaches, for example, indigenous peoples' and women's approaches to reproduction. Aggression and conquest rather than compassion and caring drive the population-control establishment and the larger model of technological-capitalist development that it represents.

Indeed, understanding and empathy require patience; but, according to its advocates, population control is urgent; it cannot lose time. Thus, terminal and high-tech methods are seen as being quicker, easier, and more efficient to administer than women-controlled methods of fertility control. However, myopic vision arising out of self-interest and fear leads to dangerous policies of gender, race, and class oppression. If unchallenged and unchecked, neo-Malthusian family planning could become an even greater tool of authoritarianism and social engineering in the future than it has been in the past. A shift from population control to birth control, from external domination to greater individual control over reproduction, can only be achieved through fundamental transformation of the global political-economic order and the dominant ideologies of both religious fundamentalism and neo-Malthusianism.

Reproduction is a highly political issue and it is unlikely that in the long term either the problem of population stabilization or the global social crisis will be resolved by political repression or high technology. Questions pertaining to democracy and authoritarianism are embedded in the structures of the society. Widespread protests against forced sterilizations in India under the Emergency imposed by Indira Gandhi were a major factor in her defeat in the subsequent elections. Field
researchers who have observed grassroots reactions to coercive population-control policies in India have warned that mounting dissatisfaction could again lead to conflict and violence as it did under the Emergency.

In China too, despite state authoritarianism, there have been outbursts and protests against family-planning policies, and the government has had to soften its policies on a number of occasions. Reporters who have traveled in the Chinese countryside have observed that the government's population policy has caused "a mixture of anger, support, frustration, enthusiasm, deviousness and pain" and that the "desire to procreate" stirs more emotion than any desire for political democracy (cited in Bandarage, 1997, p. 102).

Toward Democratic Reproductive Rights

A democratic and sustainable approach to human reproduction must incorporate social, ethical, and ecological criteria avoiding the dogmatism and extremism of both pronatalist right-wing religious fundamentalism and antinatalist neo-Malthusian family planning. Appropriate technology and democratic social relations must define the realm of human biological reproduction as they must the realm of economic production. Numerical targets and economic incentives must be abolished from family-planning programs in the south and they must not be extended to the north. Quality health-care services and a range of safe contraceptives that help protect people against STDS and HIV/AIDS are required. Development of safe male contraceptives is essential for greater male-female partnership in birth control and family planning. Abortion should not be used as a contraceptive method, but safe and legal abortions should be available to women who need them. Given that abortion is a painful decision for women, there must be social support and compassion for women to make their own decisions. Where needed, safe methods of infertility treatment should also be made available to poor women, not merely fertility control.

Reproductive rights cannot be realized where the basic material needs of people are not met. Education, employment, and access to other economic resources are essential if people are to make their family-planning decisions freely. Thus, the very definitions of reproduction and family planning need to be enlarged to include the material needs of individuals, families, and communities. Continued avoidance of basic health and economic survival issues will only enable religious fundamentalist groups to present themselves as the guardians of family and community. This is beginning to happen in the area of HIV/AIDS prevention, which has been relatively neglected by family planners. The powerful evangelical Christian movement in the United States is beginning to take a leadership role in international HIV/AIDS prevention with the backing of the current U.S. government. While efforts to eradicate the deadly disease need to be welcomed, it is important to recognize that the fundamentalist Christians may use the opportunity to propagate their own moral values with regard to sexuality and gender norms and to advocate abstinence over protected sex.

In many regions, poverty eradication is also falling into the hands of internationally funded religious fundamentalist groups. Evangelical Christian groups in particular are stepping in to fill the social and economic vacuum created by privatization of state sectors and cutbacks in state social welfare accompanying economic globalization. But unlike the family planners who provide economic incentives to the poor for acceptance of sterilization or contraception, the religious proselytizers require religious conversion to their faith and the acceptance of their moral injunctions. These developments are adding further confusion and complexity to societies already torn asunder by other political-economic and cultural contradictions.

If poverty eradication is to be genuine, it must go beyond economic incentives given in exchange for contraceptive acceptance or religious conversion. In the long-term, poverty eradication calls for setting limits on corporate profit-making and on the widening gaps between the north and the south and between the rich and the poor within countries. In order to have democratic family planning, overconsumption of resources by rich families needs to be reduced and underconsumption by poor families needs to be augmented. The optimum balance between human well-being and environmental sustainability can be achieved through rational use of natural resources, sustainable economic production, and more equitable consumption.

The concepts of family and community need to be further extended, recognizing that childbirth and human reproduction are increasingly taking place outside male-headed nuclear families. It is necessary to find a more democratic approach toward reproductive rights and human liberation that transcends the extremes of both patriarchal right-wing fundamentalism and top-down authoritarian family planning. To do so, a balance needs to be struck between the traditional role of the self-sacrificing mother and the modern role of the individualist career woman. To find a middle path, women need support from men, their families, communities, work places, and the larger world. To confront the extraordinary challenges facing humanity, it is essential to create more loving and sustainable families. Family planning needs to move beyond the narrow focus of fertility control to treating humanity, if not all planetary life, as one extended family.

bibliography

Bandarage, Asoka. "Ethnic and Religious Tension in the World: A Political-Economic Perspective." In Global Political Economy and the Wealth of Nations, edited by Philip O'Hara. London: Routledge, 2004.

Family Planning

Family Planning

Family planning is both a descriptive term and an organizational one. It was originally conceived as a public relations effort to emphasize the broadened scope of those involved in the struggle to spread the concept of birth control. The term achieved popularity in England before it did in the United States, and in May 1939, various British birth control groups amalgamated into the Family Planning Association, including in their program treatment for infertility and minor gynecological problems, child spacing, and contraceptive instruction and equipment. In the United States the name of the American Birth Control League was changed to the Planned Parenthood Federation in 1941 to emphasize the broad focus of family planning. The Planned Parenthood name was also adopted by the international federation that formed after the end of World War II, and family planning or planned parenthood became universal descriptors.

Broadly defined, family planning is the act of making a conscious plan about the number and timing of children's births. Timing may include the time of the first birth, the amount of space between births, and when to stop having children. It can include abortion, a discussion of the various means of contraception, and fertility testing and even treatment. Family planning involves not only the individual or couple, but society as well.

Methods and Effectiveness

People have consciously or unconsciously engaged in family planning throughout history. Abstinence, either lifelong or temporary, and prohibitions forbidding intercourse during certain times of the year or during certain festivals effectively curtail the fertility rate (the number of live births for each women during her lifetime). Separation of husbands and wives for long periods of time by war or business trips also curtails the fertility rate.

Abortion has often been used to limit family size, and descriptions of abortifacients, or agents that cause abortion, can be found in the herbal and other folklore of women and midwives of most societies. The deliberate abandonment of infants and young children, even killing of newborns, has not been uncommon in the past or even in some areas of the world today. Although the early Christian Church outlawed infanticide, it emphasized the stigma of illegitimacy, which meant that out-of-wedlock infants were brought to overcrowded orphanages and monasteries, where the majority of them died of starvation or disease within a few months.

Prolonged lactation is also a factor in spacing births. Lactation and the stimulus of the infant sucking ordinarily suppresses ovulation and menstruation, but it is highly effective as a birth control mechanism only when the infant consumes nothing but breast milk or when couples normally abstain from intercourse during lactation. As partial weaning takes place—as early as four to six months—the menstrual cycle returns in most women who are adequately nourished, and pregnancy is again possible.

Numerous devices such as condoms and IUDS (intrauterine devices) have been and still are used in family planning. Alternate methods of intercourse, including withdrawal and anal intercourse, also lessen the chance of pregnancy. One of the earliest results of the use of broad-scale methods sufficient to affect national fertility was the decline in the French birth rate from the end of the eighteenth century, a decline attributed to the widespread use of coitus interruptus (Van de Walle 1978). The continuing search for means of controlling contraception emphasizes an almost universal desire for humans to gain some control over the number and spacing of births.

The effectiveness of family planning is measured by the fertility rate, the total number of live births a woman at age fifty would have had. The replacement rate for a stable population is over two and under three. In the twentieth century, many countries had fertility rates below the replacement ratio but still gained population because people were living longer and several generations of a family were alive at the same time. In determining potential rates of increase without any family planning, demographers traditionally have used Hutterite women as their maximum standard for potential. The Hutterites are members of a religious denomination (in the northern United States and Southern Canada) who in the past did not use any method of family planning, although evidence suggests that this is changing. Their living standard is not luxurious, but their food supply is more than adequate, and they are regarded as very healthy. Hutterite women bore an average of twelve children in the early part of the twentieth century (Coale 1971), and this has been considered the maximum for a totally uninhibited rate of fertility that only could reached under the best possible conditions. Current fertility rates in some countries of the Third World, such as Saudi Arabia, Malawi, and Rwanda, were between seven and eight at the beginning of the 1990s, but even these had dropped to between six and seven at the end of the decade (International Planned Parenthood Federation 2002), indicating the growing influence of family planning.

Social Regulation

Organized efforts at family planning began to appear in the nineteenth century although, as in the case of France, some forces were at work earlier. The nineteenth-century efforts were started by individuals concerned with the poverty and malnutrition that seemed to be endemic among large families. Governmental bodies initially paid little attention to such efforts, and when they did they often opposed the advocates of family planning. In the United States, for example, governmental agencies such as the post office in the last part of the nineteenth century classified family planning materials as pornography. At the beginning of the twentieth century, President Theodore Roosevelt compared women who avoided pregnancy to men who refused to serve in the armed services in time of great national emergency. He argued that U.S. women had a patriotic duty to have children. Not until the last part of the twentieth century did governments in general take direct or indirect action to encourage family planning. This concern came primarily because of a growing concern about overpopulation, but it also reflected the growing influence of women on national policy.

At the beginning of the Industrial Revolution in the eighteenth century, the world population was estimated at 750 million. With growing urbanization and industrialization, growth escalated rapidly, reaching one billion in 1830, two billion in 1930, three billion in 1960, five billion by 1990, and six billion in 2000. It will probably continue to grow— unless there is radical change in trends—until 2020, after which a slow decline will begin. The growth, as indicated above, is due to declining mortality as the standard of living and sanitation have improved and communicable diseases controlled. The most rapid growth has not been in the highly industrialized countries but in those that have not yet industrialized. As the standard of living has risen in Western Europe, the United States, and similar countries, the fertility rate by 1990 had already fallen below two and in some as low as one and three-tenths (Green 1992).

Most countries have relied on education in family planning to lower fertility rates, although more drastic means have also been used. In India, for example, the government of the late Indira Gandhi was forced to cut back on their program because it was alleged that sterilization was being forced on the less educated peasants. The problem of overpopulation is compounded in many of the underdeveloped countries because the largest segment of their population is in the childbearing years. In these places, even with the more or less drastic lowering of fertility ratios, population will continue to grow. The People's Republic of China in the 1980s became the first country in the world to embark on a deliberate and comprehensive course to reach zero population growth by the end of 2000 or as soon after that as possible. In spite of drastic efforts to limit families to one child, forcing families in the cities to get permission to even try to get pregnant, and the use of drastic sterilization and abortion programs, the country failed to meet its goal, and its population in 2001 was nearly 1,300,000,000. It is, however, well on its way to doing so, and soon it will be surpassed as the country with the largest population by India (which stands at 1,034,000,000).

The Chinese policy uses, on the one hand, the carrot and stick, with promises of better schooling and other rewards for families who have only one child, and on the other hand, forced abortions or sterilizations for those who have more. In 1993 the government approved a bill to forbid marriages of persons with hepatitis and other sexually transmitted diseases, mental illness, and congenital disabilities, but the Chinese experiment emphasizes the difficulty that even authoritarian states have in encouraging family planning. In the United States, where the fertility rate is under two, in the year 2000 more than 30 percent of the women did not use any modern mechanical or chemical method of contraception. Half of the U.S. pregnancies are believed to be unplanned or unwanted, a rate that is higher than in most other industrial countries. This is one reason for the high—although declining— abortion rate in the United States. Most of the pregnancies in the United States occurred among women who came from disadvantaged backgrounds and were under twenty-five. This suggests that in general, not everyone in the United States has fully changed to the belief in an overpopulated world. How much they should change their beliefs is a matter of public discussion. That fact that not all the U.S. states gave people access to contraception until 1965, and that abortions were prohibited until 1973, emphasizes the difficulty family planning had in being accepted.

Evidence suggests that about 600 million people use contraception, and millions more would do so if they had access to high-quality services. To reach them, family planning advocates have adopted an educational four-point program that points out what family planning does: First, it saves women's lives. Avoiding unintended pregnancies could prevent about one-fourth of all maternal deaths in developing countries. Using contraceptives helps women avoid unsafe abortions, limit birth to their healthiest childbearing years, and prevent giving birth more times than is good for their health. Second, family planning saves children's lives. Spacing pregnancies at least two years apart helps women have healthier children and improves the odds of infants' survival by about 50 percent. Limiting births to a woman's healthiest childbearing years also improves her children's chances of surviving and remaining healthy. Third, women are given more choices. Controlling their own childbearing by using effective contraception can open the door to education, employment, and community involvement. Couples who have fewer children are more likely to send their daughters as well as sons to schools. Fourth, family planning encourages the adoption of safer sexual behavior. All sexually active people need to protect themselves against sexually transmitted infections (STIs), including HIV/AIDS. Using condoms or avoiding sex except in a mutually monogamous relationship are the best ways to do so. Advocates also emphasize that effective family planning helps protect the environment and aids economic development by slowing population growth.

Although governments increasingly have taken an active role in pushing family planning, many professionals believe that the keys to success are also encouraging individual advocacy—presenting
stories of people's personal experiences showing how family planning improves individual lives— and encouraging nongovernmental organized groups to carry out educational campaigns. Several published guides on advocacy are available, including International Planned Parenthood Federation's Advocacy Guide and the Population Information Program at Johns Hopkins University, A Frame for Advocacy. The optimal situation for family planning involves a discussion between both members of the couple before they begin to have sexual relations and includes a sharing of mutual hopes and desires to make sure they are sufficiently congruent to achieve a good marriage or partnership. These discussions should include all aspects of planning (whether marriage will occur and when, whether children are planned and when, and the number and spacing of children). They should consider early in the discussion whether the individual man or woman wants to have children. Most young people want at least one child, although they may change their minds over time. If a couple decides to have children, they must then plan the number of children. People make these decisions in the context of the norms of their individual groups, although it is good to keep in mind that such norms can also change, which emphasizes the need for ongoing discussion.

Infertility

Perhaps the best indicator of the North American and increasingly worldwide desire for children is the growing ongoing concern with infertility, something that is also part of family planning. Somewhere between 10 and 15 percent of all couples have difficulty conceiving, with the causes about equally divided between men and women. Major causes include venereal infections, failure to ovulate, low sperm count, obstructions in either the male or female reproductive organs, and impenetrable cervical mucus. Sometimes these problems can be treated with antibiotics, surgery, or hormones. If these methods fail, couples may also try artificial insemination or in vitro fertilization— approaches that have have been successful for many couples. The down side to their use, however, is that now that these technological approaches to conception are available, some couples feel obligated to try to have a baby. The complex approaches, including in vitro fertilizations, are expensive, time consuming, and often disappointing.

Conclusion

Ideal family planning includes consideration of the timing of marriage, number and spacing of children, and when the first and last births will occur. It requires that couples discuss sexuality, contraception, and other long-range plans such as schooling or work plans that affect births. North Americans still do little of this planning, and teenagers receive insufficient instruction about these topics. Family planning should be an important part of the modern lifestyle. If individuals do not take on this responsibility, there is always the potential that government, as in the case of China, will see a need to intervene.

coale, a. j. (1971). "the decline of fertility in europe from the french revolution to world war ii." in fertility and family planning: a world view, ed. s. j. behrman, l. cors, jr., and r. freedman. ann arbor: university of michigan press.

Family Planning

Family Planning

Family planning is a term created in the mid-twentieth century to refer to the ability to control reproduction through access to contraception, abortion, and sterilization, in addition to access to information and education. Reproductive control allows a woman to determine when and whether she will have children. A woman’s ability to control the birth and spacing of her children has a direct impact on her educational, economic, and social opportunities. A woman’s enjoyment of heterosexual activity can be affected by the fear of becoming pregnant if she lacks information about, or access to, contraception and abortion.

Women have found ways to control their reproduction since the earliest days of recorded history. However, these methods have not always been safe or effective. By 1900, every method of contraception (chemical, barrier, and natural means) had been invented, except for the anovulant method (the contraceptive pill and related methods of hormone regulation developed in the mid-twentieth century). Access to contraception was limited by law or by technological inferiority. In the United States, contraception and abortion were available through midwives, with a variety of contraceptive methods also available in the open market and through the advice of friends and family. With industrialization, urbanization, and the advent of new reproductive technologies, there was a shift away from women’s ability to control their reproductive lives. By 1900, every state had criminalized abortion in most circumstances. In 1873 Congress passed the Act of the Suppression of Trade in and Circulation of, Obscene Literature and Articles of Immoral Use. The Comstock Law, as it was known, was named for the U.S. Postal agent, Anthony Comstock (1844–1915), who lobbied for the bill’s passage. The law criminalized, among other things, the distribution of information and materials related to contraception and abortion through the U.S. mail. Legal or not, women often found means of controlling their reproduction, utilizing methods which were sometimes ineffective, dangerous, or in some cases deadly.

In the first decades of the twentieth century, social activists such as Margaret Sanger (1879–1966) and some members of the medical profession initiated a campaign for legalized contraception. Sanger was born into a large working-class family. She attended nursing school and later served as an obstetrical nurse in the Lower East Side of New York City. From her experiences as a nurse and as a child among eleven in her family of origin (her mother died at a young age as a result of multiple pregnancies within a short span of years), Sanger recognized the connection between the inability to regulate fertility and families’ economic struggles as well as women’s health. Later in life, Sanger would recall stories of women who begged her for information on how to avoid having more children or who fell ill and in some cases died as a result of a botched, illegal abortion.

Sanger’s efforts to find information on safe, legal, and effective means to regulate women’s fertility merged easily with her socialist perspective. In her socialist-feminist periodical, The Woman Rebel, Sanger first coined the term birth control in 1914. In the same year, she authored and published a pamphlet on methods of contraception, Family Limitation, based on her research on techniques and technologies of contraception available around the world. With her international research in hand, Sanger opened the first birth control clinic in the United States in 1916. One year later, she began to publish the periodical Birth Control Review. For more than a decade, the Birth Control Review provided readers with news and information on the fight for the legalization of contraception in the United States and overseas. In addition, Sanger traveled widely, organizing speaking tours and international conferences in an effort to coordinate the efforts of medical and social advocates for birth control. Thanks to the work of Sanger and others like her, by the mid-1930s various court rulings allowed contraception to be more widely available in the United States. Sanger’s American Birth Control League (founded in 1921) merged with other advocacy groups to become the Planned Parenthood Federation of America in 1942.

Sanger’s socialist roots in the birth control movement later evolved into a mainstream call for “planned parenthood”—the appropriate spacing of pregnancies to protect the health of mothers and children. The advent of the contraceptive pill in the United States in the 1960s led to a philosophical shift from birth control as a means of spacing pregnancies to a connection with the women’s liberation movement—freeing women from a fear of pregnancy, allowing them to focus on their careers and shape their own destiny.

Sanger remains a controversial figure in American history. Because she founded Planned Parenthood, critics of abortion connect her work with the abortion services offered at Planned Parenthood clinics across the country. In vilifying its founder, they attempt to discredit her organization. However, Sanger repeatedly separated the provision of abortion from contraception. She believed that contraception was the best way to prevent abortion. A second controversy attached to Sanger is the assertion that she was racist. This is the result of her reliance on eugenics discourse in her speeches and articles in the 1920s and 1930s. Her support for the provision of contraception in the African American community and overseas (in China, for example) has fueled this argument. Eugenics, the science of selective breeding, has a long history. Before World War II (1939–1945), it was a term invoked by many in mainstream society, including politicians, physicians, and professors. Eugenicists often called for the use (sometimes compulsory) of birth control (sterilization or contraception) to create a more stable, wealthier society by eliminating society’s weakest elements. While some in the eugenics movement focused on health concerns (mental and physical problems), others concentrated on moral concerns (alcoholism and criminal behavior). At its most extreme, racial prejudice led Caucasian middle- and upper-class eugenicists to blame the burgeoning African American and immigrant communities for the nation’s problems. An examination of Sanger’s perspective on eugenics reveals that her focus was on health and economic improvement (smaller families have a higher standard of living) and was not specifically connected with race.

Contraception was still illegal in many states in the mid-twentieth century until the U.S. Supreme Court, in Griswold v. Connecticut, overturned a Connecticut law banning contraceptive use in 1965. The Court ruling legalized contraceptive access for all married persons, based on the right to privacy. In 1972, in Eisenstadt v. Baird, the Court expanded the right to access to contraceptives to include unmarried people—again, based on the right to privacy. The same right was invoked in the Roe v. Wade decision in 1973, when the U.S. Supreme Court legalized abortion in the first two trimesters of a pregnancy.

Within years of the Roe v. Wade ruling, reproductive rights were again limited by law. Between 1996 and 2004, 335 new state laws were created to restrict access to abortion services. Access to abortion was limited by income (the prohibition on Medicaid funding for abortions) and age (parental consent laws instituted at the state level). Other obstacles to access were also created in many states, such as waiting periods mandated between the time of the consultation and the procedure. By 2004 just 13 percent of U.S. counties had an abortion provider. This was the result of both restrictive state legislative action and violence (and the threat of violence) against clinics and clinic personnel.

In 1999 the U.S. Food and Drug Administration approved emergency contraceptives (the “morning-after pill”) for distribution with a prescription. Emergency contraception is a stronger dose of the standard contraceptive (anovulant) pill and is effective within seventy-two hours of unprotected intercourse. It prevents the implantation of a zygote (if there is one) on the uterine wall. As its name suggests, it is intended to prevent pregnancy if contraception fails or in the case of sexual assault. In 2006, following years of politically charged debate, the FDA approved emergency contraception for over-the-counter sales (without a prescription) for women over age eighteen.

A chemical abortifacient, RU-486 (named for the French pharmaceutical company Roussel-Uclaf, which patented it), was approved by the FDA in 2000. Women in Europe had used the drug since 1988. In U.S. tests, RU-486 was shown to be 92 percent effective in terminating pregnancies before the seventh week of gestation. The abortion pill was heralded as an alternative to surgical abortion, providing a more private experience—away from the clinics that are the focal point for abortion protesters.

Immediately following the Roe v. Wade decision, the religious and conservative right organized opposition to abortion. However, legislative lobbying and clinic protests against abortion have widened in scope to attacks on certain contraceptive methods. Those who believe life begins at conception see some methods—the contraceptive pill, the “morning-after pill,” and intrauterine devices—as abortifacients because they act to prevent pregnancy after a zygote has been created. Physicians and pharmacists opposed to abortion may refuse to prescribe, or fill prescriptions for, these forms of contraception. Pro-choice forces, on the other hand, hope to prevent abortion through increased access to contraception and comprehensive sex education. Because abortion is a debate of absolutes, pro-life and pro-choice forces will continue to be engaged in this issue.

fam·i·ly plan·ning •
n. [often as adj.]
the practice of controlling the number of children in a family and the intervals between their births, particularly by means of artificial contraception or voluntary sterilization:
family-planning clinics. ∎
artificial contraception.